Provider Demographics
NPI:1376524140
Name:LICKING, JOHN R (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:LICKING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 ALTOS OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5401
Mailing Address - Country:US
Mailing Address - Phone:408-736-6255
Mailing Address - Fax:408-736-6100
Practice Address - Street 1:730 ALTOS OAKS DR
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5401
Practice Address - Country:US
Practice Address - Phone:408-736-6255
Practice Address - Fax:408-736-6100
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21321OtherCA